Tintinalli's Emergency Medicine > Section 3: Resuscitative Problems and Techniques > Chapter 19. Tracheal Intubation and Mechanical Ventilation >
Tracheal Intubation and Mechanical Ventilation: Introduction
Airway integrity, assurance of oxygenation, ventilation, and prevention of aspiration are the mainstays of emergency airway management. The indications for tracheal intubation in the emergency setting most commonly include correction of hypoxia or hypercarbia, prevention of impending hypoventilation, and ensuring maintenance of a patent airway. Secondary indications include provision of a route for resuscitative medication administration and to permit temporizing paralysis during diagnostic testing.
The most reliable way to ensure a patent airway, provide oxygenation and ventilation, and prevent aspiration is endotracheal intubation. Many unconscious and even conscious patients may be unable to spontaneously clear the airway of secretions, may require mechanical ventilation, may have aspirated, or lack protective airway reflexes.1
The clinical assessment of oxygenation and ventilation may be unreliable in a chaotic emergency department (ED). Continuous, noninvasive bedside monitoring of arterial oxygen saturation is helpful. Isolated oximetry does not assess the status of alveolar ventilation, whereas capnography does allow estimation of the partial pressure of carbon dioxide (PaCO2) based on the waveform display of the end-tidal partial pressure of carbon dioxide. Capnometry refers to the numerical display. In combination, these noninvasive modalities affect decisions regarding tracheal intubation.
Checking the necessary equipment should be standard procedure for ED clinicians at the beginning of their clinical duties. The following items should be available: oral and nasal airways, different-size orotracheal tubes, an O2 setup that is appropriately connected, a self-inflating ventilation bag, different-size masks, and various sizes of Miller and Macintosh blades with the light checked and the suction attached and tested. When intubation is required, the appropriate-size tube and an additional tube (0.5 to 1 mm in diameter smaller) should be selected, and the cuffs should be checked for air leaks with a 10-mL syringe. Selecting a tube of the proper diameter is essential. The approximate sizes for endotracheal tubes are 8.0 to 8.5 mm inner diameter for an adult male and 7.5 to 8.0 mm inner diameter for an adult female. The second hole at the end of the tube above the bevel is called Murphy eye. This hole permits some uninterrupted airflow if the tip is occluded.
Endotracheal tubes (ETTs) with high-volume, low-pressure cuffs are the best design for adults. When properly inflated, thin-walled cuffs prevent aspiration better than medium-walled cuffs. The operator should test the light on the laryngoscope and then pick an appropriate-size blade. The straight Miller blade is used to physically lift the epiglottis. The curved Macintosh blade is placed in the vallecula above the epiglottis and is used to indirectly lift the epiglottis off the larynx owing to the traction on the frenulum.
The development of expertise with both blade types is desirable, because they offer different advantages. The curved blade may cause less trauma and be less likely to stimulate an airway reflex, because, when used properly, it does not directly touch the larynx. It also allows more room for adequate visualization during tube placement and is helpful in the obese patient. The straight blade is mechanically easier to insert in many patients who do not have large central incisors. Selecting the proper-size blade greatly facilitates intubation. In adults, the curved Macintosh no. 3 is the most popular, and no. 4 is more useful in large patients. The straight Miller no. 2 or 3 is popular for the same purposes.
The patient should be thoroughly preoxygenated before intubation, ideally for several minutes. Hypoxia develops more quickly in children, pregnant women, and patients in other hyperdynamic states. Flexion of the lower neck with extension at the atlantooccipital joint (sniffing position) aligns the oropharyngeal-laryngeal axis, allowing a direct view of the larynx (Figure 19-1). The inexperienced laryngoscopist's most common reasons for failure, inadequate equipment preparation and poor patient positioning, arise before using the laryngoscope.
A. Oral, pharyngeal, and laryngeal axes. B. Sniffing position.
The laryngoscope is held in the left hand, and an ETT or suction apparatus is held in the right. After dentures and any obscuring blood, secretions, or vomitus have been removed, the suction is exchanged for the ETT and inserted during the same laryngoscopy.
The blade is inserted into the right corner of the patient's mouth. If a curved Macintosh blade is used, the flange will push the tongue toward the left side of the oropharynx. If the blade is inserted directly down the middle, the tongue can force the line of sight posteriorly, which is a common reason for the putative "anterior larynx." After visualization of the arytenoids, the epiglottis is lifted directly with the straight blade or indirectly with the curved blade. The larynx is exposed by pulling the handle in the direction that it points, i.e., 90 degrees to the blade. Cocking the handle back, especially with the straight blade, risks fracturing central incisors and is ineffective at revealing the cords.
There are a variety of other straight and curved blades available. For example, the Guedel blade is a straight blade with an acute, 72-degree angle to the handle. The Schapira straight blade has a side concavity that helps cradle the large tongue and push it toward the left side of the mouth. The CLM curved laryngoscope blade has a hinged tip, which permits elevation of the epiglottis with minimal force, as the fulcrum is repositioned down within the pharynx.
One technique that avoids the most common error, i.e., overly deep insertion of the blade, is to look for the arytenoid cartilages. If only the posterior commissure is visible, an assistant should apply more pressure on the cricoid (Sellick maneuver) or perform the laryngeal lift. Another option is the "burp" technique. The larynx is manually displaced posteriorly (backward) against the cervical vertebrae, superiorly (upward), and laterally to the right (rightward pressure). To avoid error, the cuff must be seen passing completely through the cords. "Last ditch" attempts at blind passage invite anoxia. The intubator should never be reluctant to abort the attempt if visualization of the larynx is not successful. Whenever feasible, an assistant should apply steady cricoid pressure with the thumb and index finger during the intubation to help prevent aspiration.
With proper technique and practice, semirigid, malleable, blunt-tipped metal, or plastic stylets are not usually necessary for most patients. Nevertheless, a selection of proper-size stylets should be available. The tip of the stylet should not extend beyond the end of the ETT or exit Murphy eye.
One aid to intubation with direct vision is the use of a thin, flexible intubation stylet. This type of stylet can be inserted blindly around the epiglottis into the trachea. The ETT is then threaded over it into the trachea, and the stylet is removed. The Eschmann tracheal tube introducer or stylet, also known as the "gum elastic bougie," is a valuable aid for difficult oral intubations. Another option is to use the tip on the laryngeal tracheal anesthesia kit. With either stylet, orient the tube so that Murphy eye is at the 12-o'clock position.
The tube should never be forced through the vocal cords, which can result in avulsion of the arytenoid cartilages or laceration of the vocal cords. Usually, any difficulty in passing the tube is a result of the tube being too large or too soft and flexible. Directed transoral or translaryngeal anesthesia with lidocaine can help relax the cords. If anesthesia fails, aligning the bevel with the glottic opening may be successful.
The tube should be advanced until the cuff disappears below the cords. Because head motion may move the tip of the tube 1 to 2 cm, correct tube placement is a minimum of about 2 cm above the carina. From the corner of the mouth, this location is approximately 23 cm in men and 21 cm in women. The base of the pilot tube (a tube with the adapter to inflate the cuff) is usually at the level of the teeth. To avoid ischemia of the tracheal mucosa, cuff pressure should be kept below 40 cm H2O. The minimal intracuff pressure to prevent aspiration is25 cm H2O.2 The operator should secure the tube, being careful not to impede cervical venous return with the umbilical tape or fixator. The use of a modified clove-hitch knot or a commercial fixator is ideal and helps to avoid kinking the pilot tube.
Confirmation of Intubation
Endobronchial or esophageal intubation will result in hypoxia or hypercarbia. There is no clinically reliable substitute for direct visualization of the tube passing through the vocal cords. Hence the adage, "when in doubt, take it out." Nevertheless, there are a number of options to help confirm intratracheal tube positioning. Clinical assessments, including chest and epigastric auscultation, tube condensation, and symmetrical chest wall expansion, are not infallible in the ED. "Breath sounds" from the stomach can be transmitted through the chest after gastric insufflation.
The two basic categories of confirmatory adjuncts are end-tidal CO2 (ETCO2) detectors or monitors and esophageal detection devices. Both have advantages provided that the operator remains cognizant of the sources of interpretation error. Capnometers measure CO2 in the expired air. The most commonly used capnometric devices in the ED are colorimetric, with a pH-sensitive purple filter paper. When in contact with CO2, hydrogen ions are formed, resulting in color changes according to the concentration of CO2. For example, with the Nellcor Easy Cap II, the paper turns yellow after exposure to 2 to 5 percent ETCO2, which is equivalent to 15 to 38 mm Hg PCo2. There is no color change, the filter paper remains purple, with an ETCO2 of less than 0.5 percent, equivalent to less than 4 mm Hg PCo2. Colorimetric capnometers are useful for general readings, as in assessing proper ETT placement, but are not accurate enough when precise determinations are necessary. Capnography displays real-time characteristic CO2 waveforms.
The use of ETCO2 pressure (PETCO2) monitoring can help confirm endotracheal intubation.2 Colorimetric or infrared detection of PETCO2, however, may not occur even with proper ETT placement, during states of low pulmonary perfusion such as cardiac arrest, inadequate chest compressions during cardiopulmonary resuscitation, or massive pulmonary embolism. Another cause of false-negative interpretations is massive obesity. Severe pulmonary edema may obstruct the ETCO2 or PETCO2 monitor with secretions. Alternatively, there may be an initial false-positive detection of CO2 after esophageal intubation if carbonated beverages have been ingested by the patient or for a few minutes after bolus sodium bicarbonate administration. Another cause is gastric distention resulting from bag-valve-mask (BVM) ventilation. A heated humidifier or nebulizer or epinephrine instilled through the ETT also can cause false-positive interpretations.
After intubation and cuff inflation, the capnometer is attached to the ETT. Then a BVM unit is attached to the detector, and the patient is given about six ventilations to wash out residual CO2. The PETCO2 monitor is then checked for color changes. If capnography is available, a persistent positive capnograph formation after clear and direct visualization of tube placement approaches certainty. On rare occasion, misplacement of the hypopharyngeal glottic tube tip may result in misleadingly normal oximetry and capnography. This error can be recognized by the inadequate depth of tube insertion or inadequate ventilatory volumes or on chest x-ray.
Esophageal detection devices also offer the potential to accurately determine tube location. The various designs depend on their proper function as inline aspirators of the ETT. The device adaptors fit over the 15-mm ETT connector. One advantage of the esophageal detection devices is that accuracy does not depend on adequate cardiac output and pulmonary perfusion. Rather, proper functioning is predicated on the anatomic differences between the esophagus and the trachea. When the ETT is in the esophagus, the soft, non-cartilaginous walls will collapse, and air cannot be aspirated easily.
To perform the syringe aspiration technique, the device should be attached after intubation but before ventilation. The syringe plunger should then be retracted. Resistance to aspiration reflects occlusion from esophageal collapse. If there is no resistance during aspiration, then the tube is assumed to be in the trachea. If a self-inflating bulb is used, the bulb should be compressed and then attached to the ETT. One advantage of the bulb is that it requires one hand.
The emergency physician should never assume that continued airway patency is assured after ETT insertion.3 Repeated suctioning is necessary to prevent thrombotic or inspissated secretions from obstructing the tube. Endobronchial ball-valve obstruction also can be caused by a clot. The clot can impair ventilation and produce hyperinflation of individual lobes. Cuff displacement or overinflation can result in ball-valve obstruction of the airway. Cuffs inflated in the field during frigid conditions will expand with warming. If tracheal ball-valve obstruction is suspected, the cuff should be deflated. If the tube is blocked, deflation will allow exhalation.
There are many other correctable intubation complications that should be kept in mind. If the ETT cuff leaks after the intubation, the inflation valve should be checked, because it may be defective. One simple remedy is to attach a three-way stopcock to the valve, re-inflate the cuff, and turn off the stopcock. A cuff that seems to be leaking slowly might be sealable. One type of sealant involves instilling an aspirable mixture of normal saline and 2 percent lidocaine jelly, at a 3:1 ratio, into the cuff.
If the ETT needs to be replaced, a tube changer might be considered. There are many commercially available, semirigid catheters that include 15-mm adaptors or connectors to permit ventilation during the tube exchange. These devices have quick-connect adapters that incorporate through-lumen designs to ensure adequate airflow during the procedure.
Although uncommon, morbidity related to emergent endotracheal intubation does occur and may be quite debilitating. Arytenoid cartilage avulsion or displacement, usually on the right, prevents the patient from phonating properly. Intubation of the pyriform sinus and pharyngeal-esophageal perforation has been reported. Chordal synechiae may develop anteriorly, or commissural stenosis can develop posteriorly.
Subglottic stenosis is the most disastrous sequela. The physician should avoid cuff overinflation and attempt to minimize tube motion in the larynx and trachea. Subglottic stenosis usually occurs in patients with poorly secured tubes who are combative or on ventilators.
Alternative Airway Management Techniques
Nasotracheal intubation (NTI) is an essential psychomotor skill that may be useful in many difficult situations. Operators adept at rapid sequence intubation (RSI) and NTI are in the best position to assess and act on the following prime considerations: What are the potential risks and benefits to having spontaneous respirations preserved rather than ablated? Is there a safe alternative in this patient that may avoid precipitating the need for a potentially unnecessary surgical airway?
Nasal intubation is helpful in situations where laryngoscopy or cricothyrotomy may be difficult and neuromuscular blockade hazardous.4 Severely dyspneic patients with congestive heart failure, chronic obstructive pulmonary disease, or asthma and who are awake often cannot remain supine but can tolerate NTI in the sitting position. It may be impossible to align the oropharyngeal-laryngeal axis in patients with arthritis, masseter spasm, temporomandibular dislocation, or recent oral surgical procedures. Patients with a peculiar body habitus may be difficult to intubate orally. Other considerations for NTI include persistent trismus from seizures, facial trauma, infection, tetanus, or decorticate-decerebrate rigidity. Patients with certain neuromuscular disorders or dystrophies or significant electrolyte abnormalities are not ideal candidates for oral intubation.
To minimize epistaxis, both nares should be sprayed with a topical vasoconstrictor anesthetic. During the brief period for the anesthetic to take effect, a cuffed ETT 0.5 to 1 mm smaller than optimal for oral intubation should be selected. The integrity of the cuff should be verified, and the tube adapter should be checked to ensure a snug fit. Because secretions and blood may be expelled into the air and onto the intubator's face, universal precautions should be observed. An option in addition to a face shield is the use of a protective filtering adapter, such as the Humid-Vent 1, which can be attached to the proximal end of the ETT (Gibeck Respiration, Stockholm, Sweden).
The tube, lubricated with a water-soluble (2 percent lidocaine or K-Y) jelly, is advanced along the nasal floor on the more patent side. Abrasions of the Kiesselbach plexus can be minimized by having the bevel face the septum. Steady, gentle pressure or slow rotation of the tube usually bypasses small obstructions. Passage of the tube is straight back toward the occiput (not upward). If the right side is not passable, the tube should be advanced along the other side before resorting to a smaller tube.
In patients with intact protective airway reflexes, directed transoral or translaryngeal anesthesia often facilitates intubation. Translaryngeal anesthesia, although not widely used in the ED, should be considered when the initial intubation attempt is unsuccessful. After palpating the superior border of the cricoid cartilage in the midline, the cricothyroid membrane is punctured with a 22- to 25-gauge 0.5- to 1-in. needle (Figure 19-2). The needle should be perpendicular to the membrane in the midline, with the point of injection just cephalad to the cricoid cartilage. Aspirate air, swiftly inject 1.5 to 2.0 mL of 4 percent lidocaine (sterile for injection), and press the site firmly with one finger for a few seconds. This technique prevents small degrees of subcutaneous emphysema that would erroneously suggest a laryngeal injury. Translaryngeal anesthesia is contraindicated if the landmarks are obscured by thyroid or tumor impingement on the cricothyroid membrane and in obese or combative patients.
Translaryngeal anesthesia via cricothyroid puncture. A. Anatomy, anterior view. B. Anatomy, cross-sectional view. Same landmarks as those for translaryngeal ventilation.
An assistant should immobilize the patient's head and initially maintain it in a neutral or slightly extended position ("sniffing position"). The physician should stand beside the patient, with one hand on the tube and with the thumb and index finger of the other hand straddling the larynx. The tube is then advanced while rotating it medially 15 to 30 degrees until maximal airflow is heard through the tube. Then the tube is gently but somewhat swiftly advanced. The best time for advancement is at the initiation of inspiration. Entrance into the larynx may initiate a cough, and most expired air should exit through the tube even though the cuff is uninflated. The presence of any vocal sounds indicates a failed attempt.
The advancement of the tube toward the carina can be observed externally. The normal distance from the external nares to the carina is 32 cm in the adult male and 27 to 28 cm in the adult female. Therefore, before obtaining a chest x-ray, the optimal initial depth of tube placement for NTI in adults, measured at the nares, is 28 cm in men and 26 cm in women. Standard tube confirmation techniques should be performed. Secretions or blood in the tube should be removed before initiating positive-pressure ventilation.
If intubation is unsuccessful, the neck is carefully inspected to determine malposition of the tube. Most commonly, the tube is in the pyriform fossa on the same side as the nostril used. A bulge will be seen and can be palpated laterally. The tube is withdrawn into the retropharynx until breath sounds are heard. The tube is then redirected while the larynx is manually displaced toward the bulge. If there is no contraindication, flexion and rotation of the neck to the ipsilateral side while the tube is rotated medially often is effective.
The other most common tube misplacement is posteriorly in the esophagus. There are no breath sounds through the tube, and the trachea is slightly elevated. The intubator should attempt redirection after extending the patient's head and performing Sellick maneuver. When cervical spine pathology is suspected, a directional tip-control tube (Endotrol) or a fiberoptic laryngoscope should be considered. Endotrol tubes smaller than 7.5 mm (inner diameter) tend to soften and obstruct and can be difficult to suction. However, the use of these directional-tip tubes often improves the success rate of the first attempt at NTI.
When the tube hangs up on the vocal cords, shrill, turbulent air noises will be heard. The tube can be rotated slightly to realign the bevel with the cords. Alternatively, 2 mL of 4 percent lidocaine (80 mg) can be administered down through the tube onto the cords if transoral or translaryngeal anesthesia was omitted.
Nasal intubation with a fiberoptic laryngoscope may be required when neoplastic lesions, lymphoid tissue, Ludwig angina, peritonsillar abscess, or epiglottitis obstructs the pharynx. The presence of facial trauma does not appear to be a contraindication to NTI.5 Complex nasal and massive midfacial fractures and bleeding disorders are relative contraindications to NTI.
Conversely, oral intubation can impede prompt reduction and stabilization of some maxillary fractures. Because a LeFort I fracture does not extend to the cribriform plate, it is not a contraindication. Fiberoptic guidance or RSI is preferable for LeFort II and III fractures.
The risk of inadvertent intracranial passage of a nasotracheal tube is extremely low, unlike that with nasogastric tube insertion. Very poor technique in the setting of obvious massive head trauma would be required for such an outcome. Severe traumatic nasal or pharyngeal hemorrhage may necessitate orotracheal intubation or cricothyrotomy. Contamination of the spinal fluid is a hazard with some basilar skull fractures.
Serious complications of NTI are rare. In a number of large series, there was no permanent laryngeal damage. Epistaxis will occur with inadequate topical vasoconstriction, excessive tube size, poor technique, or anatomic defects. Excessive force can damage the nasal septum or turbinates.
Frequent suctioning, especially if epistaxis or other upper airway hemorrhage is present, will help to prevent thrombotic occlusion of the tube or a mainstem bronchus. Retropharyngeal lacerations, abscesses, and nasal necrosis have been reported.
Paranasal sinusitis, especially occurring with prolonged NTI or severe cranial trauma, can be an unrecognized source of sepsis. The risk of postintubation sinusitis correlates with the duration of intubation, which often reflects the neurologic insult. In the setting of craniofacial trauma, any subsequent computed tomographic scans should include views of the paranasal sinuses. Other factors causing sinusitis include the presence of a nasogastric tube, sinus hemorrhage or fracture, and administration of glucocorticoids.
Digital intubation is an underused, noninvasive technique for ETT insertion. The performance of this maneuver requires tactile recognition of the epiglottis. Visual landmarks may be impossible to identify with a laryngoscope, because of patient positioning, anatomic disruption, or significant hemorrhage. Tactile digital intubation can avert cricothyrotomy when direct laryngoscopy after neuromuscular blockade has failed. Patients with micrognathia or temporomandibular immobility are poor candidates for this technique.